Provider Demographics
NPI:1982254298
Name:RODRIGUEZ, GARY RAY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:RAY
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23811 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-2275
Mailing Address - Country:US
Mailing Address - Phone:951-290-1175
Mailing Address - Fax:
Practice Address - Street 1:27808 CLOUD DANCE CT
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92585-9005
Practice Address - Country:US
Practice Address - Phone:951-443-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician